Client Information

Client Information
Today's Date:*

MonthDayYear
Date
Client Name:*
Social Security Number*
Date of Birth:*

MonthDayYear
Date
Age:*
Sex (biological):*
Gender (how you identify):*
Ethnicity:*
Home Address:*
Home Phone Number:*
Mobile Number:*
May we leave a message?*
Email address:*
example@example.com
Referral Source
Who may we thank for your referral to our office, or how did your learn about our practice?*
Emergency Contact Information
In case of an emergency, who should we contact?*
Relationship:*
Phone Number:*
Client History
Who is providing the history information here?*
Please provide any details regarding what brought you to counseling:*
Previous Treatment
Have you received or participated in previous counseling and/or therapy?*
Was the treatment you received helpful?*
Have you had hospital stays for psychological concerns? *
Additional Information:
Medical History

List any current or important past medications:
Medication & Dose:*
Response to Medication:*
Any current health concerns, serious illnesses, or conditions:*
Indicate any allergies you have:*
How would you rate your current physical health?*
What was the approx date of your last physical or routine health “check up?*

MonthDayYear
Date
Marital History
Which best describes your marital status?*
Do you have children (please include stepchildren or any children for whom you are responsible)?*
If yes, please give first name, gender, and age for each one:
Do you have custody of your children?*
Are there presently any child custody issues involving you or your family? *
Does your family currently have Child Protective Services Involvement?*
Legal History
Do you currently have any pending criminal?*
Are you on probation?*
Have you ever been arrested/convicted of a crime other than traffic misdemeanors?*
If you answered yes to any of these three questions, please explain:
Safety
Have you recently (within the last two weeks) experienced any thoughts of harming either yourself or someone else?*
Have you in the past experienced thoughts of harming either yourself or someone else?*
Have you ever attempted to kill yourself?*
Have you ever physically attacked or been in a physical altercation with someone else?*
If you answered yes to any of the above please explain in as much detail as possible:
Fee Agreement
Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Primary Insurance Provider*
Secondary Insurance Provider*
Primary Insurer ID:*
Secondary Insurer ID:*
Copy of Identification (Driver's License)*

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Copy of Insurance Card*

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*No copay or out of pocket costs for clients with Medicaid plans.
Self Pay Rates:

Individual Session: $85.00

Couples/Family Session: $100
**Missed Appointment/Late Cancellation: Equal to your session fee
I, (client or parent/guardian), authorize Poppy’s Therapeutic Corner to charge my credit card via the Square, Ivy Pay or Theranest after each session.

I authorize Poppy’s Therapeutic Corner, LLC to charge my credit card in the case of an emergency (imminent risk of harm to self or others).

If services are office or telebased, I understand that I will not be present every time my card is billed. I understand that I need to notify my therapist in writing to discontinue services and for my credit card to stop being charged for services. I understand that my information will be saved to file for future transactions on my account.
Client Responsibilities and Fee Information
- Each person is expected to pay his/her fee at the time of service.
- Notify your therapist if there are any changes to your insurance benefits or if your insurance is discontinued.
- No shows or cancellations without a 24 hour notice will be charged the self-pay cost of the session, which is not reimbursable by insurance. No show fees do not apply to school-based clients.
- All inquiries into pre-certification, benefits, treatment plans (if necessary), coverage, etc. are the client’s responsibility.
- Payment is expected at the time of service and the client has the ultimate responsibility for their account and making sure insurance payment is received if using insurance.
- If a claim is denied it is the client’s responsibility to pay their account upon notification of denial at the insurance reimbursement rate. If payment is not received for services rendered in a timely manner I understand that Poppy’s Therapeutic Corner, LLC will release my information to a third party Credit agency to attempt to collect my debt. The information provided to the Credit agency will only be demographic information in order to collect this debt.
- Poppy’s Therapeutic Corner, LLC has your permission to release your protected health information to your insurance company.
- In order to receive services from Poppy’s Therapeutic Corner, LLC you are agreeing to the conditions outlined above
Client or Parent/Guardian Signature*

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Today's Date*

MonthDayYear
Date
Please verify that you are human*
**Your Credit Card will not be charged once you click submit**
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Client Information

Referral Source

Emergency Contact Information

Client History

Previous Treatment

Medical History

Marital History

Legal History

Safety

Fee Agreement